My Life as A Physical Therapist – Part 7

Written by: Yaffa Liebermann PT, GCS,CEO

Tel Aviv, Israel

After five years in Virginia, we moved back to Israel, and resided in Savyon not far from Tel Hashomer hospital

I got a part time job at Tel Hashomer hospital, which is one of the premier hospitals in Israel, as a fill in therapist. Each day I covered for missing therapists treating patients suffering from COPD, Pneumonia, and Cystic Fibrosis, all of whom had breathing difficulties. I started the day at the internal medicine department, treating patients who suffered from lung dysfunction. We did breathing exercises, vibration and percussion to help clear the airways, by loosening the mucus in the lungs, to enable the patient to breathe better.

I asked my patients to lie down prior to my arrival, 15 minutes on the right side and 15 minutes on the left side to let gravity drain the mucus from the lung to one side and then to the opposite side. The purpose was to shake it inside, like you shake a thick gravy in a bottle prior to pouring it out.  Then the patient received chest physical therapy. Only then were they recommended to eat their breakfast. If they sat and walked around in the morning prior to the treatment, the gravity would pull the secretion down, making it difficult to loosen and get out.

Teaching Clapping Techniques

Some patients were deconditioned to the point that they were hardly able to walk 10 feet, making them fearful of moving, which in turn led to chest muscles tightening, resulting in shortness of breath and difficulty with performing activities of daily living. My goal was to help them clear the lungs by teaching them proper breathing techniques, as well as strengthening and flexibility exercises. This process with a session every morning typically took 10 days, and by that time the patient got stronger and could be discharged.

I learned from this experiences that professionals need to share their knowledge with the patients clearly and directly. As an example, I encouraged them to drink, as I felt that they were not drinking enough because they disliked drinking the hospital served tea, I suggested asking their visiting family members to bring them different kinds of juices. Within a week their bedside tables were filled with colored bottles of juice, and I was elated.

I became very interested in treating pulmonary cases, and later I developed a pulmonary program consisting of 12 sessions, each session consisted of increasing muscles strength, joints flexibility and increasing their ability to breathe out, as exercise intensity increased every session. I taught the patients that when lungs are not completely cleared of carbon dioxide, they do not have the full capacity to expand and inhale oxygen. Panic and asthma attacks stimulate the nervous system and cause spasms in smooth bronchiolar muscles, thereby obstructing breathing.

Child with Asthma Attack Practicing Breathing Out

My friend was 40 years old at the time and suffered from about 20 Asthmatic attacks every winter. She described the family situation when she would get the Asthma Attack in the middle of the night: She started to cough, it got stronger and she was not able to lay in bed and to breathe. She then sat on the edge of the bed continually coughing. Her two children would emerge from their room to see if they must dress up and be ready to go to grandparents on the way to the hospital. Her husband would sit by her on the bed waiting to see if he needs to dress up and drive. They all were helpless and waiting to see whether the mother gets over it or they need to take her to the hospital.

I taught her husband how to give massage to her upper trapezius- the shoulder girdle, then guide her to bend the upper body forward and breathe out with a calm voice. No one instructed patient and the family did not know yet, that they could actually help rather than just sit and watch. My friend told me that the knowledge and the help reduced her asthmatic attacks from 20 time in a winter to just 2. She shared this treatment with Asthmatic friends and I shared it with therapists wherever I could.

Practicing Correct Breathing

Caregivers can help alleviate symptoms of dyspnea in people of all ages: they can help children in a state of tension; teach patients with chronic respiratory diseases how to live within the limitations of their physical status; provide respiratory support in medical crises; assist clients to adopt their lifestyles to a specific level of wellness.

A physical and occupational therapist can establish a breathing program for patients such as long exhalation (breathing out) versus short inhalation (breathing in) ratio 2:1. Long exhalations empty the lungs of carbon dioxide and makes space available for oxygenated air which is necessary for breathing.


Strategies to reduce dyspnea include:

Sitting Straight and Using an Inhaler

  • Drink water before going to sleep so mucus on bronchiole walls does not become dry.
  • Self-postural drainage can keep secretions from pooling. Lay 10 minutes on your right side, 10 minutes on the left side, and 10 minutes on your stomach while still in bed.  By moving directly into an upright position, secretions settle and become difficult to expel.
  • Keep your trunk flexible by performing rotation, side flexion, and extension exercises.  Good posture with mobility in the joints enables the movement necessary for breathing.
  • Practice long exhalation throughout the day. A child may play with a cotton ball by blowing on it; a student may blow into a crumpled lunch bag; a patient may exhale while transferring from the bed to a standing position or performing any difficult task.
  • Maintain good posture for proper use of an inhaler. Breathe in and out three times to clear lungs. Read directions and expand your chest when breathing in.
  • Establish a 2-1 breathing program, exhaling to the count of six and inhaling to the count of three. This exercise will clear the lungs and create a psychological diversion. A good way to practice is to walk up six stairs while breathing out and three more stairs while breathing in.
  • Incorporate breathing with everyday activities.  When lifting the knee up, breathe out, so the compressed air will go out from the body when the trunk is flexed.  Breathe in when the trunk is being stretched and elongated, so the expansion of the lungs will leave room for oxygenated air.

Caregivers can use the following techniques to support patients in a stressful situation:

  • Remind the patient to breathe out with pursed lips.
  • Massage the upper back starting in the muscles between the spine and scapula and work your hands up to the upper trapezius.  Apply pressure when the patient exhales and lighten pressure when the patient inhales.
  • Put light pressure on the sternum and upper thoracic spine during exhalation, to remind patients in a state of panic how to breath correctly.

Tissue Test

Tissue test: Patients can evaluate their own progress by measuring the length of time in seconds, that they can breathe out. This is a functional measurable tissue test prepared by Lyntte C. Kurtz, PT and was published in the Physical Therapy Forum 1990. The test is performed as follows:

Patient should hold a tissue 20” away from his mouth, choose a stopwatch function on the cell phone, sit up straight and breathe out into the tissue to see how long it’s been moving. The patient should practice the tissue test three times in a row and then stop and breathe regularly. The best time recorded in the three tests, can be documented, and evaluated once a week. The results will determine the patient’s ability:

1 – 3 seconds – Bed bound

3 – 5 seconds – Able to get to bedside commode, sponge bath with moderate breathing distress

5 – 7 seconds – Able to sit at a table for meals, get safely to bathroom with some breathing distress

7 – 15 seconds – Comfortable ADL’s and level ambulation

15 – 20 seconds – Flight of stairs with minimal breathing distress

20 – 25 seconds – Functional adult

25+ seconds – Swimmer, marathon runner, etc.

Practicing in Rehab

Although this blog addressed treatment of patients with respiratory diseases, many people could also use correct breathing techniques. Runners, swimmers, extremely active children, athletic teenagers, and others may achieve greater results when they use long exhalation during periods of physical stress.  As a patient develops confidence, he can trust his own body. The mind and body work together to overcome episodes of labored breathing to make life more comfortable.

Please share this information.

Next blog will address treating stroke patients.


  1. Roxie Jackson on January 23, 2021 at 4:03 pm

    I feel like I have been reading chapters out of a New York best seller book? The life of Yaffa Lieberman in the 1960’s in the world of Rehabilitation. Thank you! On to the next chapter. Questions what cause the Liebermann family to return to Israel? What cause them to relocate back to the US? How did Yaffa know the importance of taking photos to capture her time experiences? Thank you for sharing!!!

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